5.4 Points on anesthetic consideration in airway, chest and heart trauma

These patients are benefited if they are managed with specialist in the field of anesthesia, cardiothoracic surgeon and with resourceful hospital having intensive care unit. However, if the patient condition does not allow referring to better hospital the following should be considered. 

• Resuscitation and anesthetic care are directed toward airway control, maintenance of adequate pulmonary ventilation, and management of blood loss 
• In the setting of airway injury blind intubation techniques are contraindicated. Over sedation and neuromuscular relaxants are also best avoided as these may result in loss of the airway. Emergency cricothyroidotomy or surgical tracheostomy may be required.
• Chest tube placement should be strongly considered in any patient with pneumothorax if general anesthesia with tracheal intubation and positive pressure ventilation is required. 
• In patients with airway or breathing difficulty, early intubation and initiation of positive pressure ventilation should be considered. 
• For large, open chest wall defects, surgical debridement of dead and devitalized tissue and closure of the wound are often required under general anesthesia. 
• Even in the absence of other thoracic injury, a patient with a flail thoracic segment may require mechanical ventilation to reduce the work of breathing 
• Myocardial contusion can have an impact on anesthetic management. Specifically these patients are at increased risk for hypotension and dysrhythmia. Patients who display any dysrhythmia during a procedure or have hypotensive episodes attributed to myocardial contusion should have increased postoperative observation and monitoring. 
• For cardiac and great vessel trauma, the anesthetist should secure multiple large-bore venous access to allow for rapid fluid administration of fluid as required. Bilateral chest tube placement should be considered prior to or coincident with anesthetic induction because of the risk of pneumothorax. The choice of induction agents is less important than the selection of an appropriate dose. Ketamine and etomidate are a favored induction agent. 
• Repeated manipulation of the heart often results in intermittent episodes of bradycardia and profound hypotension. 
• In general, the anesthetic consideration to emergency and trauma patient should be considered here